Research in Gerontological Nursing

Research Brief 

Describing Older Adults' Awareness of Fall Risk Using Situation Awareness Research Techniques: A Pilot Study

Jo Azzarello, PhD, RN; Beth Hall, PhD, RN

Abstract

The purpose of the current study was to evaluate efficacy of techniques adapted from situation awareness research for describing how older adults perceive and understand fall risk factors in the context of daily routine. Eleven older adults watched a video of an older woman performing daily activities. Thirteen intrinsic, extrinsic, and behavioral fall risks were embedded throughout the scenario. The video was periodically frozen/blanked from view while participants answered questions about their understanding of the situation and associated story elements. Participants perceived a variety of fall risk factors but did not necessarily interpret them as indicating fall risk. Many fall risks held non-fall meaning for participants (e.g., newspapers on the floor meant the woman liked to read). Although four participants readily identified a fall risk situation, seven did not until they were explicitly asked to consider safety. Study techniques were effective for describing situation awareness of fall risk and several suggestions for improvement are described.

[Res Gerontol Nurs. 2016; 9(4):161–166.]

Abstract

The purpose of the current study was to evaluate efficacy of techniques adapted from situation awareness research for describing how older adults perceive and understand fall risk factors in the context of daily routine. Eleven older adults watched a video of an older woman performing daily activities. Thirteen intrinsic, extrinsic, and behavioral fall risks were embedded throughout the scenario. The video was periodically frozen/blanked from view while participants answered questions about their understanding of the situation and associated story elements. Participants perceived a variety of fall risk factors but did not necessarily interpret them as indicating fall risk. Many fall risks held non-fall meaning for participants (e.g., newspapers on the floor meant the woman liked to read). Although four participants readily identified a fall risk situation, seven did not until they were explicitly asked to consider safety. Study techniques were effective for describing situation awareness of fall risk and several suggestions for improvement are described.

[Res Gerontol Nurs. 2016; 9(4):161–166.]

Falls are the leading cause of fatal and nonfatal injuries in adults 65 and older (Centers for Disease Control and Prevention, 2015), but those at risk vary in perceptions of their vulnerability. When asked what factors place an individual at risk for a fall, older adults generally reported influences such as muscle weakness, balance problems, medications, dizziness, and failure to use assistive devices (Vivrette, Rubenstein, Martin, Josephson, & Kramer, 2011). However, many older adults with one or more fall risk factors fail to see themselves at risk for falling (Wiens, Koleba, Jones, & Feeny, 2006) and are unlikely to practice fall prevention strategies. Findings from aviation and driving safety research show accident prevention demands more than knowledge of risk factors—it requires awareness of the situation as a whole with accurate comprehension of the meaning and significance of what is perceived (Gugerty, 2011).

Much of what is known about older adults' understanding of fall risk is from studies where participants know fall prevention is being investigated, which makes it likely they are aware they should think and respond within the context of safety. Exploring how older adults comprehend fall risks outside the explicit context of safety could provide insights about their risk awareness during daily life. These questions are important in designing innovative measures to improve fall risk awareness, yet search of the literature found no studies applied situation awareness research methods to investigate fall prevention. Therefore, the current pilot study was conducted to: (a) explore how older adults think about fall risk factors in the context of daily routines; (b) examine the efficacy of situation awareness measurement techniques for describing situation awareness of fall risk; and (c) identify modifications needed for designing a larger study. Investigative techniques adapted from situation awareness research in other fields were used to describe perceptions of fall risk factors embedded in a scenario of daily life, how fall risk factors were used to understand the current situation and project the future state of events, and what effect prompts to consider safety had on awareness of fall risk.

Background and Significance

In the current study, situation awareness is considered as how one perceives and interprets the meaning of factors in the environment. Situation awareness is typically conceptualized as comprising three distinct levels, each dependent upon and interacting with one another (Endsley, 2006). Situation awareness Level 1 is perception of information. Situation awareness Level 2 is comprehension of the meaning of perceived information, including recognition of patterns and ability to differentiate between relevant and irrelevant cues. Situation awareness Level 3 is anticipation or prediction of future conditions based on perception and comprehension. An individual's underlying cognitive representation, or mental model, of a system or condition plays a significant role in situation awareness and influences where attention is directed, underlies understanding of the significance of perceived information, and provides a mechanism for projecting future states (Endsley, 2006). Situation awareness provides the basis of decision making and behavior and can be a significant source of errors. Individuals who do not perceive, understand, and anticipate hazardous situations are more prone to accidents, whereas heightened situation awareness in hazardous situations informs better decisions and improved safety outcomes (Durso, Truitt, Hackworth, Crutchfield, & Manning, 1998).

Measurement approaches for situation awareness vary among safety experts and several excellent reviews provide details of situation awareness measurement (Jones & Endsley, 2004; Salmon et al., 2009). Situation awareness measurements are usually classified as indirect or direct. Indirect measures of situation awareness occur post-activity and require subjective assessment, such as asking an individual to self-rate his/her situation awareness. Direct measures are more objective and capture situation awareness in real-time with questions corresponding to situation awareness levels. Most often, the situation of interest is presented to participants as a computer-based simulation. Questions are posed either during the ongoing simulation so that participants answer while the situation unfolds or while the simulation is periodically frozen and blanked from view (i.e., freeze/blank questioning). After participants answer the questions, the simulation continues.

There are several advantages to using freeze/blank questioning for investigations of situation awareness of fall risk. It avoids reliance on participants' ability to accurately evaluate their own situation awareness. In addition, stopping the simulation before questioning prevents participants from missing information in an ongoing scenario due to distraction. Without stopping the simulation, it would be difficult to distinguish whether participants missed a particular fall risk because of poor situation awareness or because they looked away from the screen to answer at the time the fall risk appeared. Finally, if the simulation is not blanked, a question might cue participants to search for additional information in the situation that otherwise would have gone unnoticed.

Techniques for measuring situation awareness are adaptable and can be used in a variety of areas by designing a content-specific simulation and question probes for the task being evaluated (Endsley, 1995). In the current study, situation awareness research approaches were adapted for investigating older adults' situation awareness of fall risk by using a video scenario of an older adult's daily routine with multiple fall risk factors embedded. Situation awareness question probes were developed so that they did not specifically reference falls to avoid influencing participants' thoughts.

Method

A descriptive design with convenience sampling was used to examine community-dwelling older adults' situation awareness of fall risk. After obtaining institutional review board approval, participants were recruited from an older adult health center and through key contacts (e.g., professional colleagues). Eligible adults were 65 and older living independently in the community who understood and spoke English, could adequately see and hear information presented via a laptop computer, had no history of cognitive impairment, and scored ≥3 on the Mini-Cog Assessment tool (Borson, Scanlan, Watanabe, Tu, & Lessig, 2005). Of 14 individuals who responded to recruitment flyers, two declined to participate and one scored <3 on the Mini-Cog Assessment. Eleven participants (six were from the older adult health center and five were recruited through key contacts) completed the study.

Measures

Mini-Cog Assessment. Participants were screened for cognitive function, memory, language comprehension, and visual motor skills using a brief assessment tool. A score of ≥3 on the Mini-Cog indicated low likelihood of cognitive impairment (Borson et al., 2005). The Mini-Cog is as effective as the Mini-Mental State Examination in detecting dementia and cognitive impairment in community-dwelling older adults, including those with low literacy levels (Borson et al., 2005).

Situation Awareness of Fall Risk. A freeze/blank questioning technique was used to measure situation awareness of fall risk in a short video simulating experiences in the life of a fictitious older woman, Carol, who is at risk for falls. The scenario depicted Carol thinking aloud as she performed daily activities, such as waiting for a friend and babysitting grandchildren. Thirteen intrinsic, extrinsic, and behavioral fall risk factors were embedded throughout the scenario. Fall risk elements appeared visually (e.g., newspapers on the floor), as spoken statements reflecting Carol's thoughts (e.g., “I feel so dizzy”), or illustrated through Carol's behaviors (e.g., walking on a bare floor wearing socks), and were never explicitly identified as fall risks. Multiple non-fall–related elements were also dispersed throughout the scenario, which served as indicators of non-fall situations and added realism to the story. After 4.5 minutes, the simulation was frozen/blanked and the investigator (B.H.) posed open-ended questions to elicit how participants comprehended the situation in the scenario (situation awareness Level 2) (e.g., “What are your impressions about Carol's situation?”). Questions also probed for perceived elements participants used to form their understanding (e.g., “What elements in the story led you to think that?”).

The video was restarted and the simulation continued with introduction of additional fall risk elements (e.g., trip items in a doorway) as Carol hurried into another room after hearing a loud crash. After 1 minute, the simulation was frozen/blanked and the investigator posed open-ended questions to elicit what participants thought the situation in the scenario would be like in the next few minutes (situation awareness Level 3) (e.g., “What do you think will happen next with Carol?”), as well as the perceived elements used in forming their prediction. If during questioning for situation awareness Levels 2 or 3 a participant did not indicate that the situation posed risk for a fall, the investigator's final question specifically cued him/her to consider safety (e.g., “Thinking about everything you saw or heard in the video, what are some possible safety issues for Carol?”). Participant responses were digitally recorded and transcribed for analysis. Prior to data collection, participants practiced the situation awareness Levels 2 and 3 freeze/blank questions with a non-fall–related video.

Participants then completed an item recognition task (IRT) with a sample of five fall risk items from the simulation: items on the floor in a doorway, Carol's cane, a throw rug, newspapers on the floor, and a statement of feeling wobbly. These fall risks, plus a sample of five non-fall risk elements from the simulation and four elements that did not appear in the simulation, were presented one at a time in a random order. Participants were asked if they saw or heard each element in the video. The number of fall risk items participants stated they perceived during the IRT was used as a measure of Level 1 situation awareness of fall risk. The simulation and IRT were presented using MediaLab research software version 2014.

Demographics. Lastly, participants completed a short demographic questionnaire including questions on fall history and use of assistive devices.

Analysis

Content analysis of transcribed responses to questions posed during freeze/blanks was conducted using an a priori coding scheme to identify statements related to falls and the scenario's fall risk elements. Most participants comprehended multiple facets of Carol's situation (e.g., nutrition, financial). However, the study focus was on fall risk so only statements related to falls and fall risk elements were coded. Researchers (J.A., B.H.) independently coded the transcripts and periodically met to review and compare coding. Inter-coder agreement for participants' interpretation of current and future situations, safety-cued situations, and elements cited were greater than 85%. Dissimilar coding was reviewed and discussed until mutual agreement was reached.

Coded data differentiated participants who stated without prompts that Carol was at risk for a fall from those who only indicated falls when specifically cued to consider safety. Coded data were also used to identify types of non-fall interpretations of the fall risks. Frequencies that fall risk elements were mentioned for fall and non-fall situations were compared to explore relevance of the fall risks for understanding the situation. Although infrequently cited fall risks may indicate less relevancy, participants may not have mentioned a specific fall risk element as a fall situation simply because it was not perceived. This differentiation has implications for identifying the source of limited fall risk awareness as perception or understanding. To explore this issue, the frequency that the five fall risk factors from the IRT were cited in understanding Carol's situation as a fall hazard was examined for participants who perceived them.

Results

All 11 participants were Caucasian and seven were female. Five participants were ages 70 to 79, and the remainder were equally divided between ages 65 to 69 and 80 to 89. Three participants were single and four were married or widowed. Six participants reported having fallen within the past 2 years. One participant reported using an assistive device for ambulation. All participants stated they could see and hear the simulation without difficulty and were able to follow procedures. Most participants commented that Carol's situation was similar in some ways to their own. Participation lasted approximately 45 minutes.

No participant showed evidence of response bias in the IRT. Of five fall risk elements included in the task, the mean number perceived was 3.73 (SD = 1.01). Three participants (27.3%) reported perceiving all five fall risks. Three participants (27.3%) perceived four fall risks, four (36.4%) reported perceiving three, and one (9.1%) perceived two.

Initial questions during freeze/blanks aimed to elicit participants' under-standing of a fall risk situation without an imposed context. After the first freeze/blank, three participants (27.3%) identified Carol as at-risk for a fall. After the second freeze/blank, two participants who previously identified fall risk plus an additional participant predicted Carol might fall in the near future. Seven participants (63.6%) did not identify fall issues and were prompted to consider Carol's situation within the context of safety; once the idea of safety was introduced, they stated Carol was at risk for a fall.

The majority of participants (n = 9, 81.8%) indicated one or more non-fall situations based on the scenario's fall risk elements (Table 1). Examples included: Carol is not fit to babysit her grandchildren and likes to read. Participants who cited items in the doorway and distraction understood them as issues related to the grandchildren rather than a situation involving Carol. Walking on a bare floor wearing socks was understood to mean that Carol might injure her feet.


Participants' Non-Fall Interpretations of Fall Risk Factors

Table 1:

Participants' Non-Fall Interpretations of Fall Risk Factors

When asked what story elements led them to their understandings of Carol's situation, participants cited one to three fall risk elements per situation (fall: mean = 2, SD = 0.78; non-fall: mean = 1.43, SD = 0.57). The number of participants who cited the scenario's fall risk factors as the basis for their understanding of fall and non-fall situations are presented in Table 2. Carol's cane appeared to be a relevant story element to participants. Hurrying and newspapers on the floor also appeared relevant for understanding Carol's fall potential; each were cited by one third of participants. Items in the doorway, taking multiple medications, and walking on a bare floor in socks appeared more relevant to participants' understanding of the situation as a non-fall compared to a fall. Distraction was equally stated as an indicator of a fall or non-fall situation. Two fall risks were not cited for understanding any aspect of Carol's situation.


Participants Who Cited Fall Risk Factors as Indicating Fall and Non-Fall Situations (N = 11)

Table 2:

Participants Who Cited Fall Risk Factors as Indicating Fall and Non-Fall Situations (N = 11)

The number of participants who perceived five fall risk elements in the IRT and who cited them as indicating a fall situation are presented in Table 3. All participants saw Carol's cane and heard her say she felt wobbly. Therefore, when participants did not indicate these fall risks in their understanding, it was not because these items were not perceived, but perhaps because they did not comprehend their significance. Not all participants perceived the other three fall risk factors, providing a rationale for why some did not cite them. For participants who perceived them, newspapers on the floor appeared most relevant for understanding a fall situation.


Participants Who Perceived Scenario Fall Risk Factors and Cited Them as Indicating a Fall Situation (N = 11)

Table 3:

Participants Who Perceived Scenario Fall Risk Factors and Cited Them as Indicating a Fall Situation (N = 11)

Discussion

Situation awareness measurement techniques in the current study were effective for describing situation aware ness of fall risk in a small sample of community-dwelling older adults. Participants reported seeing or hearing a variety of fall risk factors in the scenario but did not necessarily understand them as meaning the situation posed fall risk. Many fall risks held non-fall meaning for participants. Although some participants readily understood the scenario's situation as involving risk for a fall, for others it was not until an explicit context of safety was imposed that they considered the situation as posing a fall hazard.

The IRT as a measure of situation awareness Level 1 was generally satisfactory and participants easily followed instructions. However, the researchers noted limitations. A sample of fall risk items from the scenario was used due to concern about possible participant fatigue after answering open-ended questions. It was thought that five fall risks would provide an adequate estimate of perception of scenario fall risks. However, during freeze/blank questioning, many fall risk items were rarely or never cited. Beyond the five fall risks included in the IRT, it was impossible to tell if participants did not mention a fall risk because it was not perceived (situation awareness Level 1) or because it was considered irrelevant (situation awareness Level 2). Including all scenario fall risks in the IRT might eliminate this problem and seems feasible considering there was no evidence of participant fatigue. In addition, some fall risk images used in the IRT were from different angles or distance than in the video (e.g., items in the doorway appeared at medium range in the video but were presented from a higher angle and closer for the IRT). Some participants were unsure if the question about seeing the item referred to seeing it from the specific angle/distance in the image or seeing it anywhere in the scenario. Using screen-shots for the IRT might alleviate this issue.

Open-ended questions were effective in eliciting situation awareness Level 2 understanding of the situation and situation awareness Level 3 projection of future events. Participants identified various fall and non-fall situations based on what they saw and heard and readily cited the scenario elements on which they based their understandings and projections. The scenario included many fall risk factors, yet participants appeared to base understanding on only one or a few, which was helpful in identifying fall risk elements that participants might find irrelevant to understanding fall situations. Participants appeared to enjoy sharing their thoughts about Carol's situation, although open-ended questions may have less utility with taciturn individuals. Including a practice session using situation awareness Levels 2 and 3 questions with an unrelated video prior to data collection was effective in helping participants understand what was expected.

The nature of the questions required participants to think about conditions in the scenario free of imposed context. Presumably, participants' situation awareness was directed by their unique mental models of an older adult, which influenced where attention was directed, how information was understood, and predictions about what might happen next. For some participants, it appeared their mental model readily triggered a match between key fall risks in the scenario and understanding fall risk. Perhaps imposing the idea of safety invoked a somewhat different model for understanding the situation—one that included fall risk.

Conclusion

Situation awareness investigation procedures were useful for describing older adults' situation awareness of fall risk, and researchers were able to identify areas for improving the techniques. Older adults appear to vary in their perception of fall risks and may attribute non-fall meanings in the context of daily routine. Assessing how community-dwelling older adults interpret fall risks may expand fall prevention strategies currently used for clients whom nurses consider to be at risk for falls. Additional research is needed to explore the role of situation awareness of fall risk in fall prevention and to identify effective strategies that improve fall risk awareness.

References

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  • Gugerty, L. (2011). Situation awareness in driving. In Lee, J., Rizzo, M., Fisher, D. & Caird, J. (Eds.), Handbook for driving simulation in engineering, medicine and psychology (pp. 265–272). Boca Raton, FL: CRC Press.
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Participants' Non-Fall Interpretations of Fall Risk Factors

Fall Risk ElementsNon-Fall Interpretation
Uses caneCarol is getting older.
Carol is unfit to babysit the grandchildren.a
Someone must be helping Carol because her yard
looks well-kept.
Carol is in poor health.
Carol is like my wife.
Uses cane, feels wobblyCarol does not get around well.
Newspapers on floorCarol likes to read.
It is difficult for Carol to bend over to pick things up.
Takes multiple medications, feels dizzyCarol is not getting appropriate medical care.
Takes multiple medicationsCarol is worried about her medications.
Items in doorway, distractionCarol might find the grandchildren have fallen.
Carol might find the grandchildren knocked some-thing over.
Items in doorway, distraction, didn't use caneCarol will quickly check for damage caused by the grandchildren.
Didn't use cane, hurryingCarol might remember she forgot her cane and go back for it.
Walking on bare floor in socksCarol's feet might get cut if something broke.a

Participants Who Cited Fall Risk Factors as Indicating Fall and Non-Fall Situations (N = 11)

Fall Risk FactorFall SituationNon-Fall Situation
n (%)
Use or non-use of cane7 (63.6)7 (63.6)
Hurrying4 (36.4)1 (9.1)
Newspapers on floor4 (36.4)2 (18.2)
Distraction3 (27.3)3 (27.3)
Throw rug2 (18.2)0
Feels wobbly1 (9.1)1 (9.1)
Taking new blood pressure medication1 (9.1)0
Feeling dizzy1 (9.1)1 (9.1)
Items on floor in doorway1 (9.1)3 (27.3)
Taking multiple medications02 (18.2)
Walking on bare floor in socks02 (18.2)
Living room rug00
Feeling weak00

Participants Who Perceived Scenario Fall Risk Factors and Cited Them as Indicating a Fall Situation (N = 11)

Fall Risk FactorPerceivedCited
nn (%)
Cane117 (63.6)
Feels wobbly111 (9.1)
Newspapers on the floor84 (50)
Throw rug62 (33.3)
Items on floor in doorway51 (20)
Authors

Dr. Azzarello is Associate Professor, and Dr. Hall is Assistant Professor, Fran and Earl Ziegler College of Nursing, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma.

The authors have disclosed no potential conflicts of interest, financial or otherwise. This work was supported in part by the D. W. Reynolds Center of Geriatric Nursing Excellence.

Address correspondence to Jo Azzarello, PhD, RN, Associate Professor, Fran and Earl Ziegler College of Nursing, University of Oklahoma Health Sciences Center, 1100 N. Stonewall, Oklahoma City, OK 73117; e-mail: jo-azzarello@ouhsc.edu.

Received: December 04, 2015
Accepted: April 05, 2016
Posted Online: May 10, 2016

10.3928/19404921-20160504-01

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